Early postpartum discharge: maternal depression, breastfeeding habits and different follow-up strategies.

BACKGROUND: In most maternity wards in Norway, early discharge (<48 hour) is the norm. To monitor newborns' and women's health during the first week after delivery, most maternity wards offer early check-ups, where families return to the hospital (standard care). However, a few municipalities offer home visits by midwives (domiciliary care) to ensure seamless services for the family. AIM: The primary aim of this study was to explore whether different follow-up strategies were differently associated with maternal depression and breastfeeding habits, 6 weeks and 6 months postpartum. The secondary aim was to investigate whether families at risk of postpartum depression were included in the home visiting programme in the municipality that offered both follow-up strategies. METHOD: This study draws on data from the 'Little in Norway' (LIN) study, which followed families from pregnancy until the child was 18 months. This study used data from two different well-baby clinics in two municipalities, where one offered standard care (n = 95) and the other domiciliary (n = 64) and standard care (n = 17). The Edinburg Postnatal Depression Scale (EPDS) was used to measure maternal depression. Breastfeeding habits were measured using a self-report questionnaire. The Life Stress subscale of the Parenting Stress Index (PSI) was used to identify women at risk of postpartum depression. RESULTS: There were no differences in maternal depressive symptoms or breastfeeding habits at neither 6 weeks nor 6 months postpartum between women who received standard or domiciliary care in the two municipalities. Within the municipality that offered both follow-up strategies, a higher number of women scoring high on prenatal life stress were included in domiciliary - compared to standard care. CONCLUSION: Differential follow-up strategies in the first week after birth did not impact on maternal depression or breastfeeding habits. However, domiciliary care seems to be regarded as supportive and nonstigmatising for women at risk of postpartum depression.

Feasibility and acceptability of an early home visit intervention aimed at supporting a positive mother-infant relationship for mothers at risk of postpartum depression.

AIMS: Perinatal depression is associated with difficulties in the early mother-child interaction and negative child outcome. The aim of this study was to assess the feasibility and acceptability of the Newborn Behavioral Observation (NBO) System included in a home visiting programme at well-baby clinics in Norway and to examine compliance with the study protocol for a future clinical trial. The target group was pregnant women at risk for postpartum depression and their partners. METHOD: An open-label study was conducted. A total of 15 pregnant women and 10 partners were recruited during 24-28 weeks of gestation. The NBO was conducted in three home visits during the first four weeks after birth. Data were collected from surveys responded to by parents and healthcare workers at six time-points and from video recordings of mother-infant interaction by the Emotional Availability (EA) Scale. The parents' experience of the intervention and data collection was investigated by qualitative analyses of five interviews. The NBO is an individualised, relationship-based method aimed to strengthen the emotional bond between the parents and their infants and enhance the parents' alliance with the healthcare worker. RESULTS: Intervention completion was 97%. Data collection completion was 100% at baseline and the second time-point and dropped to 50% for the mothers and 40% for the fathers at the sixth time-point. However, 79% (11 of 14) of the mothers and infants took part in video recordings for the EA coding at 4 months postpartum (sixth time-point). The usefulness questionnaires showed high acceptability among both parents and healthcare workers. CONCLUSION: This study showed that the NBO conducted in home visits is a feasible and acceptable intervention for both parents and healthcare workers within the well-baby clinic services. A future clinical trial protocol needs adjustments related to data collection.

Maternal DHA Status during Pregnancy Has a Positive Impact on Infant Problem Solving: A Norwegian Prospective Observation Study.

Docosahexaenoic acid (DHA, 22:6, n-3) is a long-chain polyunsaturated fatty acid necessary for normal brain growth and cognitive development. Seafood and dietary supplements are the primary dietary sources of DHA. This study addresses the associations between DHA status in pregnant women and healthy, term-born infant problem-solving skills assessed using the Ages and Stages Questionnaire. The fatty acid status of maternal red blood cells (RBCs) was assessed in the 28th week of gestation and at three months postpartum. The infants’ fatty acid status (RBC) was assessed at three, six, and twelve months, and problem-solving skills were assessed at six and twelve months. Maternal DHA status in pregnancy was found to be positively associated with infants’ problem-solving skills at 12 months. This association remained significant even after controlling for the level of maternal education, a surrogate for socio-economic status. The infants’ DHA status at three months was associated with the infants’ problem solving at 12 months. The results accentuate the importance for pregnant and lactating women to have a satisfactory DHA status from dietary intake of seafood or other sources rich in DHA.

The effects of fatty fish intake on adolescents' nutritional status and associations with attention performance: results from the FINS-TEENS randomized controlled trial.

BACKGROUND: Adolescence involves changes in dietary habits that may induce imbalances in the intake of different nutrients. Fish is an important dietary source of omega-3 (n-3) long-chain polyunsaturated fatty acids (LCPUFAs), vitamin D, several minerals and high-quality protein. By using secondary outcomes and exploratory analyses, the aims of this paper were to evaluate if nutritional biomarkers (red blood cell fatty acids, serum (s)-25(OH)D, s-ferritin and urinary iodine concentration (UIC)) were altered during a dietary intervention, and if they mediated previously reported changes in attention performance. In addition, to examine the status of the biomarkers and explore associations between dietary pattern, biomarkers and attention performance cross-sectionally at baseline. METHODS: The Fish Intervention Studies-TEENS (FINS-TEENS) was a three-armed intervention trial, including adolescents from eight secondary schools (n = 415; age: 14-15y) in Bergen, Norway. Participants were individually randomized to receive either fish meals, meat meals or n-3 LCPUFA supplements, three times a week for a total of 12 weeks. Blood and urine samples were collected pre and post intervention and attention performance was assessed with the d2 test of attention. Analyses of covariance (ANCOVA) assessed differences between groups in changes of biomarkers and linear mixed models were applied in analyses of attention performance and biomarkers. The trial is registered in ClinicalTrials.gov (NCT02350322). RESULTS: At baseline, the mean omega-3 index was 5.8 ± 1.3% and deficient status were identified for s-25(OH)D (54%), s-ferritin (10%) and UIC (40%). The intervention resulted in an increase in DHA and the omega-3 index which was larger in the supplement group compared to the fish and meat group (P < 0.01), and in the fish group compared to the meat group (P < 0.01). No differences between the groups were observed for changes in 25(OH)D, s-ferritin or UIC. None of the biomarkers mediated performance in the d2 test. The intake of fatty fish and a healthy dietary pattern was associated with scores in processing speed at baseline. CONCLUSIONS: These results show that Norwegian adolescents have insufficient status of important nutrients, which may be improved with fatty fish consumption or n-3 LCPUFA supplements. However, nutritional status was not associated with scores in the d2 test of attention.

The effect of school meals with fatty fish on adolescents' self-reported symptoms for mental health: FINS-TEENS - a randomized controlled intervention trial.

There is a growing body of evidence linking fish consumption and n-3 LCPUFAs to mental health. Still, the results from randomized trials with n-3 LCPUFAs show conflicting results, and it is possible that the combined effect of several nutrients in fish may explain the observed associations. To aim of the present study was to investigate if school meals with fatty fish three times per week for 12 weeks could alter mental health in a sample of typically developing adolescents. In the Fish Intervention Studies-TEENS (FINS-TEENS), adolescents from eight secondary schools (n=425) in Norway, were randomized to receive school meals with fatty fish, meat or n-3 LCPUFA supplements. Mental health was assessed with the Strengths and Difficulties Questionnaire (SDQ) and the differences between the groups were assessed with linear mixed effect models, unadjusted and adjusted for baseline and dietary compliance. The results showed no effects of school meals with fatty fish compared to similar meals with meat or n-3 LCPUFAs on the adolescents' self-reported symptom scores for mental health. Among adolescents scoring above the SDQ cut-offs (high-scorers), the fish- improved less than the meat group in the self-reported symptom scores for total difficulties- and emotional problems. However, the findings should be regarded as preliminary, as the analyses for the high-scorer group were underpowered. In conclusion, serving school meals with fatty fish did not alter mental health in a typically developing sample of adolescents. It is possible that serving healthy school meals with meat is more beneficial than similar meals with fatty fish in adolescents scoring high on mental health problems. However, the results should be seen as preliminary, as the dietary compliance in the fish group was low and the analyses in the high score group underpowered. Thus, further studies should investigate the associations between fish consumption and adolescents' mental health.

Fatty fish intake and attention performance in 14-15 year old adolescents: FINS-TEENS - a randomized controlled trial.

BACKGROUND: Fatty fish is the dominant dietary source of n-3 LCPUFAs but it also contains other micronutrients considered important for brain development and function. To our knowledge, the effect of fatty fish intake on cognitive function in adolescents has not been investigated in randomized controlled trials (RCTs) previously. The aim of the present trial was to investigate whether consumption of fatty fish meals three times per week for 12 weeks could alter attention performance in adolescents compared to similar meals with meat or n-3 LCPUFA supplements. METHODS: In the Fish Intervention Studies-TEENS (FINS-TEENS), adolescents from eight secondary schools (n = 426; age: 14-15y) were individually randomized. Attention performance was assessed with the d2 test of attention. Differences between groups from pre to post intervention were assessed with linear mixed effect models and general estimates equation. The fish group was set as reference. Dietary compliance was recorded for each meal throughout the trial and controlled for in the adjusted analyses. RESULTS: The improvement in processing speed was significantly lower in the meat (-11.8; 95% CI: -23.3, -0.4) and supplement (-13.4; 95% CI: -24.9, -1.8) group compared to the fish group (reference). The supplement group also showed inferior improvement in total performance (-10.4; 95% CI: -20.0, -0.7) compared to the fish group (reference). The results were slightly affected when controlling for dietary compliance. Omission errors decreased in the meat group compared to the fish group (Incidence rate ratio = 0.85; 95% CI: 0.74, 0.98), but the difference disappeared when controlling for dietary compliance. CONCLUSIONS: We observed a small beneficial effect of fatty fish, compared to meat meals and supplements on processing speed. However, these results are difficult to interpret due to low dietary compliance. This study shows that different taste preferences among participants is challenging in intervention trials with food. A prospective cohort design may be a better alternative when studying diet in the future. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registration number: NCT02350322 .

Design of the FINS-TEENS study: A randomized controlled trial assessing the impact of fatty fish on cognitive performance in adolescents.

AIMS: To describe the rationale, study design, population and dietary compliance in a randomized controlled trial (RCT) investigating the effect of fatty fish on cognitive performance and mental health in adolescents. METHOD: In the Fish Intervention Studies-TEENS (FINS-TEENS) study we individually randomized 478 adolescents (14-15-year-olds) from eight secondary schools in Norway to receive school meal lunches with fatty fish or meat or n-3 supplements three times a week for 12 weeks. Demographic factors, psychological tests and biological measures were collected pre-and post-intervention. Duplicate portions of lunch meals were collected and individual intake recorded throughout the study. RESULTS: In total, 481 out of 785 adolescents (61%) agreed to participate and 34 (7%) dropped out. Breakfast consumption was the only group difference in background characteristics. Analyses of selected nutrients in the lunch meals showed higher levels of n-3 fatty acids, vitamin D and n-6 fatty acids in the fish compared to the meat meals. Dietary compliance (score 0-144) revealed that the intake in the Fish group (mean = 59, standard deviation (SD) = 35) were lower than in the Meat group (mean = 83, SD = 31, p < 0.01) and Supplement group (mean = 105, SD = 25, p < 0.01). CONCLUSIONS: The results show that it is possible to conduct a RCT with fatty fish in a school-based setting. The results also emphasize the importance of collecting detailed records of dietary compliance, as this information is important when interpreting and analysing the outcome of dietary interventions.

Affective facial expression in sub-clinically depressed and non-depressed mothers during contingent and non-contingent face-to-face interactions with their infants.

BACKGROUND: Depression in the postpartum period involves feelings of sadness, anxiety and irritability, and attenuated feelings of pleasure and comfort with the infant. Even mild- to- moderate symptoms of depression seem to have an impact on caregivers affective availability and contingent responsiveness. The aim of the present study was to investigate non-depressed and sub-clinically depressed mothers interest and affective expression during contingent and non-contingent face-to-face interaction with their infant. METHODS: The study utilized a double video (DV) set-up. The mother and the infant were presented with live real-time video sequences, which allowed for mutually responsive interaction between the mother and the infant (Live contingent sequences), or replay sequences where the interaction was set out of phase (Replay non-contingent sequences). The DV set-up consisted of five sequences: Live1-Replay1-Live2-Replay2-Live3. Based on their scores on the Edinburgh Postnatal Depression Scale (EPDS), the mothers were divided into a non-depressed and a sub-clinically depressed group (EPDS score≥6). RESULTS: A three-way split-plot ANOVA showed that the sub-clinically depressed mothers displayed the same amount of positive and negative facial affect independent of the quality of the interaction with the infants. The non-depressed mothers displayed more positive facial affect during the non-contingent than the contingent interaction sequences, while there was no such effect for negative facial affect. CONCLUSIONS: The results indicate that sub-clinically level depressive symptoms influence the mothers' affective facial expression during early face-to-face interaction with their infants. One of the clinical implications is to consider even sub-clinical depressive symptoms as a risk factor for mother-infant relationship disturbances.

A Diet Score Assessing Norwegian Adolescents' Adherence to Dietary Recommendations-Development and Test-Retest Reproducibility of the Score.

Assessment of adolescents' dietary habits is challenging. Reliable instruments to monitor dietary trends are required to promote healthier behaviours in this group. The purpose of this cross-sectional study was to assess adolescents' adherence to Norwegian dietary recommendations with a diet score and to report results from, and test-retest reliability of, the score. The diet score involved seven food groups and one physical activity indicator, and was applied to answers from a semi-quantitative food frequency questionnaire (FFQ) administered twice. Reproducibility of the score was assessed with Cohen's Kappa (κ statistics) at an interval of three months. The setting was eight lower-secondary schools in Hordaland County, Norway, and subjects were adolescents (n = 472) aged 14-15 years and their caregivers. Results showed that the proportion of adolescents consistently classified by the diet score was 87.6% (κ = 0.465). For food groups, proportions ranged from 74.0% to 91.6% (κ = 0.249 to κ = 0.573). Less than 40% of the participants were found to adhere to recommendations for frequencies of eating fruits, vegetables, added sugar, and fish. Highest compliance to recommendations was seen for choosing water as beverage and limit the intake of red meat. The score was associated with parental socioeconomic status. The diet score was found to be reproducible at an acceptable level. Health promoting work targeting adolescents should emphasize to increase the intake of recommended foods to approach nutritional guidelines.

Docosahexaenoic Acid Status in Pregnancy Determines the Maternal Docosahexaenoic Acid Status 3-, 6- and 12 Months Postpartum. Results from a Longitudinal Observational Study.

BACKGROUND: Essential fatty acid status as well as docosahexaenoic acid (DHA, 22:6n-3) declines during pregnancy and lactation. As a result, the DHA status may not be optimal for child development and may increase the risk for maternal postpartum depression. The objective of this study was to assess changes in the maternal fatty acid status from pregnancy to 12 months postpartum, and to study the impact of seafood consumption on the individual fatty acid status. METHODS: Blood samples and seafood consumption habits (gestation week 28, and three-, six- and 12 months postpartum) were collected in a longitudinal observational study of pregnant and postpartum women (n = 118). Multilevel linear modeling was used to assess both changes over time in the fatty acid status of red blood cells (RBC), and in the seafood consumption. RESULTS: Six fatty acids varied the most (>80%) across the four time points analyzed, including the derivative of the essential α-linoleic acid (ALA, 18:3n-3), DHA; the essential linoleic acid (LA, 18:2 n-6); and the LA derivative, arachidonic acid (AA, 20:4n-6). Over all, a large variation in individuals' DHA- and AA status was observed; however, over the 15-month study period only small inter-individual differences in the longitudinal trajectory of DHA- and AA abundance in the RBC were detected. The median intake of seafood was lower than recommended. Regardless, the total weekly frequency of seafood and eicosapentaenoic acid (EPA, 20:5n-3)/DHA-supplement intake predicted the maternal level of DHA (µg/g RBC). CONCLUSION: The period of depletion of the maternal DHA status during pregnancy and lactation, seem to turn to repletion from about six months postpartum towards one year after childbirth, irrespective of RBC concentration of DHA during pregnancy. Seafood and EPA/DHA-supplement intake predicted the DHA levels over time. TRIAL REGISTRATION: www.helseforskning.etikkom.no 2009/570/REC, project number: 083.09.

Low omega-3 index in pregnancy is a possible biological risk factor for postpartum depression.

BACKGROUND: Depression is a common disorder affecting 10-15% women in the postpartum period. Postpartum depression can disrupt early mother-infant interaction, and constitutes a risk factor for early child development. Recently, attention has been drawn to the hypothesis that a low intake of seafood in pregnancy can be a risk factor for postpartum depression. Seafood is a unique dietary source of the marine omega-3 fatty acids and is a natural part of a healthy balanced diet that is especially important during pregnancy. METHODS: In a community based prospective cohort in a municipality in Western Norway, we investigated both nutritional and psychological risk factors for postpartum depression. The source population was all women who were pregnant within the period November 2009 - June 2011. The fatty acid status in red blood cells was assessed in the 28(th) gestation week and participants were screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) three months after delivery. The aim of the present study was to investigate if a low omega-3 index in pregnancy is a possible risk factor for postpartum depression. RESULTS: In a simple regression model, the omega-3 index was associated with the EPDS score in a nonlinear inverse manner with an R square of 19. Thus, the low omega-3 index explained 19% of the variance in the EPDS score. The DPA content, DHA content, omega-3 index, omega-3/omega-6 ratio, total HUFA score, and the omega-3 HUFA score were all inversely correlated with the EPDS score. The EPDS scores of participants in the lowest omega-3 index quartile were significantly different to the three other omega-3 index quartiles. CONCLUSION: In this study population, a low omega-3 index in late pregnancy was associated with higher depression score three months postpartum.

Subclinical levels of maternal depression and infant sensitivity to social contingency.

The aim of the study was to investigate how young infants respond to contingent and non-contingent interaction in relation to maternal level of depressive symptoms in a non-clinical sample of mothers and infants. Two groups of three-month-olds interacted with their mother who was assessed as either non-depressed or sub-clinically depressed, based on self-reported scores on the Edinburgh Postnatal Depression Scale (EPDS). The infants were presented with a continuous image and voice of their mother in a closed circuit computer system, using the double video procedure. The experiment comprised five sequences, alternating between contingent (Live) and non-contingent (Replay) maternal behaviur in a fixed Live1-Replay1-Live2-Replay2-Live3 sequence. The infants of the sub-clinically depressed mothers showed a high gaze focus at their mother independently of the quality of interaction, while the infants of the non-depressed mothers showed a preference for looking at the mother only when the interaction with their mother was contingent. Further, the infants of the sub-clinically depressed mothers showed no differentiation in affective expression between contingent and non-contingent interactions, while the infants of the non-depressed mothers expressed more positive affect than negative affect only when the interaction with their mother was contingent. Finally, there was a significant relation between the infant's preference for looking at the mother and the infant's amount of positive affect, but this was only found for the infants of the non-depressed. These results indicate that young infants' sensitivity to social contingency is related to maternal level of depression, even in a non-clinical sample. This expands the implications of earlier findings on the impact of maternal depression on infant sensitivity to social contingency, demonstrating that even sub-clinical levels of maternal depression may effect early interaction and child development.

Establishment of a seafood index to assess the seafood consumption in pregnant women.

BACKGROUND: Seafood (fish and shellfish) is an excellent source of several essential nutrients for pregnant and lactating women. A short food frequency questionnaire (FFQ) that can be used to quantitatively estimate seafood consumption would be a valuable tool to assess seafood consumption in this group. Currently there is no such validated FFQ in Norway. OBJECTIVE: The objective of this study was to establish and validate a seafood index from a seafood FFQ against blood biomarkers (the omega-3 index, the omega-3 HUFA score, and serum 25OH vitamin D). DESIGN: We assessed maternal seafood consumption during the 28th gestation week in healthy Norwegian women (n=54) with a seafood FFQ. A seafood index was developed to convert ordinal frequency data from the FFQ into numerical scale data. The following blood biomarkers were used as a validation method: omega-3 index, omega-3 HUFA score, and the serum 25OH vitamin D. RESULTS: The reported frequency of seafood as dinner and as spread was strongly correlated with the estimated frequencies of seafood as dinner and as spread. This indicated that the seafood index is a valuable tool to aggregate reported frequencies from the seafood FFQ. The seafood index composed of the frequency of seafood consumption and intake of omega-3 supplements, termed the total seafood index, correlated positively with the omega-3 index, omega-3 HUFA score, and 25OH vitamin D. CONCLUSION: We established and validated a seafood index from a seafood FFQ. The developed seafood index can be used when studying health effects of seafood consumption in large populations. This seafood FFQ captures seafood consumption and omega-3 supplement intake considerably well in a group of pregnant women.